DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service

ASSURANCE OF COMPLIANCE BY SUB-AWARD RECIPIENTS

Regarding Procedures for Dealing With and Reporting Research Misconduct Allegations

FORM APPROVED: OMB No. 0937-0198; Expires: 05/31/2020 See Statement of Burden Below

INSTITUTIONAL OFFICIAL'S NAME

INSTITUTIONAL OFFICIAL'S TITLE

Please make any mailing changes in the space to the right:

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NAME OF INSTITUTION

MAILING ADDRESS OF INSTITUTIONAL OFFICIAL

NAME OF INSTITUTION FROM WHICH PHS FUNDS ARE RECEIVED AS SUBRECIPIENT

Section I. ORI Assurance of Compliance for Sub-Award recipientsInstitutions with U.S. Public Health Service (PHS) supported biomedical or behavioral research, research training or activities related to that research or research training must provide PHS with an assurance of compliance with the Public Health Service Policies on Research Misconduct, 42 C.F.R. Part 93.

Section II. Certification

I certify that:

(a) This institution has written policies and procedures in compliance with 42 C.F.R. Part 93 for inquiring into and investigating allegations of research misconduct; and

(b) This institution is in compliance with its own policies and procedures and the requirements of 42 C.F.R. Part 93.

Name of Official: Title:

(c) The person responsible for administering the institutions procedures, compliant with 42 CFR 93.300(b) is? (At some Institutions this person is called the Research Integrity Officer or RIO).

(d) The person responsible for “fostering a research environment that promotes the responsible conduct of research” in compliance with 42 CFR 93.300(c) is? At some institutions this person is called the RCR coordinator or administrator.

Name of Official: Title:

Official Certifying for InstitutionNAME OF OFFICIAL (Please type) TITLE

SIGNATURE DATE

TELEPHONE NUMBER

( ) FAX NUMBER

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E-MAIL ADDRESS OF OFFICIAL:

PHS-6315 (Rev. 1/18) PAGE 1 PSC Publishing Services (301) 443-6740 EF

STATEMENT OF BURDENPublic reporting burden for this collection of information is estimated to average 5 minutes to complete the form, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: OS Reports Clearance Officer, Hubert H. Humphrey Building, Room 503-H, 200 Independence Avenue, S.W., Washington, D.C. 20201 (Attn: PRA) and to: Office of Management and Budget, Paperwork Reduction Project (0937-0198) Washington, D.C. 20502. Please do not return this form to either of these addresses.

RETURN THIS FORM TO:

Assurance Program Office of Research Integrity 1101 Wootton Parkway, Suite 750 Rockville, MD 20852

Phone: (240) 453-8407 FAX: (301) 594-0039

E-Mail: Robin.Parker@hhs.gov

PHS-6315 (Rev. 1/18) PAGE 2